Noninvasive Support and Ventilation for Pediatric ARDS
Noninvasive Support and Ventilation for Pediatric ARDS
Objective Despite the widespread use of noninvasive ventilation in children and in children with acute lung injury and pediatric acute respiratory distress syndrome, there are few scientific data on the utility of this therapy. In this review, we examine the literature regarding noninvasive positive pressure ventilation and use the Research ANd Development/University of California, Los Angeles appropriateness methodology to provide strong or weak recommendations for the use of noninvasive positive pressure ventilation in children with pediatric acute respiratory distress syndrome.
Data Sources Electronic searches were made in PubMed, EMBASE, Web of Science, Cochrane Library, and Scopus with the following specific keywords: noninvasive ventilation, noninvasive positive pressure ventilation, continuous positive airway pressure, and high-flow nasal cannula.
Study Selection Studies were eligible for inclusion if they included 10 or more children between 1 month and 18 years old. Randomized and nonrandomized controlled trials, controlled before-and-after studies, concurrent cohort studies, interrupted time series studies, historically controlled studies, cohort studies, cross-sectional studies, and uncontrolled longitudinal studies were included for data synthesis.
Data Synthesis The literature provides a solid physiological rationale for the use of noninvasive positive pressure ventilation in children with pediatric acute respiratory distress syndrome. The addition of noninvasive positive pressure ventilation can improve gas exchange and potentially prevent intubation and mechanical ventilation in some children with mild pediatric acute respiratory distress syndrome. Noninvasive positive pressure ventilation is not indicated in severe pediatric acute respiratory distress syndrome. Noninvasive positive pressure ventilation should be performed only in acute care setting with experienced team, and patient-ventilator synchrony is crucial for success. An oronasal interface provides superior support, but close monitoring of children is required due to the risk of progressive respiratory failure and the potential need for intubation. The use of high-flow nasal cannula is a promising treatment for respiratory disease; however, at this time, the efficacy of high-flow nasal cannula compared with noninvasive positive pressure ventilation is unknown.
Conclusion Noninvasive positive pressure ventilation can be beneficial in children with pediatric acute respiratory distress syndrome, particularly in those with milder disease. However, further research is needed into the use of noninvasive positive pressure ventilation in children.
Respiratory failure is the most common indication for admission to a PICU, affecting more than half of all children in the PICU in a recent international study. In children, a common cause of respiratory failure is hypoxemic respiratory failure. There are several different terms for this disease process, including acute lung injury (ALI) and acute respiratory distress syndrome (ARDS). Recently, the new Berlin definition revised the classification of acute hypoxemic respiratory failure in adults and replaced the term acute lung injury with mild, moderate, and severe ARDS based on degree of hypoxemia. In this review, the new revised terminology will be used.
Noninvasive positive pressure ventilation (NPPV) is an attractive strategy for children with impending respiratory failure. Since ventilation is delivered noninvasively via mask or other interface, NPPV supports ventilation, can reduce atelectasis, and potentially unloads fatigued respiratory muscles while preserving the child's natural airway and airway clearance mechanisms. In addition, NPPV potentially avoids some of the associated complications of more invasive therapies as well as the need for sedation or muscle relaxation to facilitate these therapies.
NPPV has been used to treat respiratory failure from a variety of etiologies in children, including pediatric ARDS (PARDS). A recent point prevalence study by Santschi et al, in collaboration with the Pediatric Acute Lung Injury and Sepsis Investigators network and the European Society of Pediatric and Neonatal Intensive Care, described the ventilatory strategies for ARDS in 52 PICUs in 12 countries. The authors found significant variability in the use of NPPV among PICUs but described an overall prevalence of 8.5% for the use of NPPV in PARDS.
The use of NPPV in children has increased significantly over the last decade. In one international cohort, investigators found that the use of NPPV increased from 0.5% to 12.2% between 1999 and 2008. Additionally, in a survey of 353 U.S. physicians by Fanning et al, the investigators found that NPPV had been used by 99% of respondents, with 60% using noninvasive support as initial therapy more than 10% of the time. In this same survey, deterrents to use NPPV included lack of experience of staff, lack of appropriate equipment, and proper patient selection. Physicians also reported factors associated with less likelihood of use including severe defects in gas exchange, disease progression, and patient intolerability.
Despite the growing use of this therapy, there are few prospective controlled trials in pediatrics that might guide the clinician in determining indications and strategies for the use of NPPV. Additionally, many studies of NPPV in children include all children with acute respiratory failure and do not differentiate between PARDS and other etiologies. A recent Cochrane review confirmed this assessment, stating that there was a lack of well-designed controlled experiments of NPPV in children with acute hypoxemic respiratory failure.
In this review, we will examine the literature to determine the utility of NPPV in this population and provide recommendations regarding the use of NPPV in children with PARDS. Of note, as the data specific to the use of NPPV in PARDS are limited, the recommendations in this section of the Pediatric Acute Lung Injury Consensus Conference (PALICC) proceedings, while still agreed upon, are less strongly so than in other PALICC topics where scientific literature is more plentiful. Therefore, we suggest that the use of NPPV in PARDS should be considered a crucial research priority in the near future.
Abstract and Introduction
Abstract
Objective Despite the widespread use of noninvasive ventilation in children and in children with acute lung injury and pediatric acute respiratory distress syndrome, there are few scientific data on the utility of this therapy. In this review, we examine the literature regarding noninvasive positive pressure ventilation and use the Research ANd Development/University of California, Los Angeles appropriateness methodology to provide strong or weak recommendations for the use of noninvasive positive pressure ventilation in children with pediatric acute respiratory distress syndrome.
Data Sources Electronic searches were made in PubMed, EMBASE, Web of Science, Cochrane Library, and Scopus with the following specific keywords: noninvasive ventilation, noninvasive positive pressure ventilation, continuous positive airway pressure, and high-flow nasal cannula.
Study Selection Studies were eligible for inclusion if they included 10 or more children between 1 month and 18 years old. Randomized and nonrandomized controlled trials, controlled before-and-after studies, concurrent cohort studies, interrupted time series studies, historically controlled studies, cohort studies, cross-sectional studies, and uncontrolled longitudinal studies were included for data synthesis.
Data Synthesis The literature provides a solid physiological rationale for the use of noninvasive positive pressure ventilation in children with pediatric acute respiratory distress syndrome. The addition of noninvasive positive pressure ventilation can improve gas exchange and potentially prevent intubation and mechanical ventilation in some children with mild pediatric acute respiratory distress syndrome. Noninvasive positive pressure ventilation is not indicated in severe pediatric acute respiratory distress syndrome. Noninvasive positive pressure ventilation should be performed only in acute care setting with experienced team, and patient-ventilator synchrony is crucial for success. An oronasal interface provides superior support, but close monitoring of children is required due to the risk of progressive respiratory failure and the potential need for intubation. The use of high-flow nasal cannula is a promising treatment for respiratory disease; however, at this time, the efficacy of high-flow nasal cannula compared with noninvasive positive pressure ventilation is unknown.
Conclusion Noninvasive positive pressure ventilation can be beneficial in children with pediatric acute respiratory distress syndrome, particularly in those with milder disease. However, further research is needed into the use of noninvasive positive pressure ventilation in children.
Introduction
Respiratory failure is the most common indication for admission to a PICU, affecting more than half of all children in the PICU in a recent international study. In children, a common cause of respiratory failure is hypoxemic respiratory failure. There are several different terms for this disease process, including acute lung injury (ALI) and acute respiratory distress syndrome (ARDS). Recently, the new Berlin definition revised the classification of acute hypoxemic respiratory failure in adults and replaced the term acute lung injury with mild, moderate, and severe ARDS based on degree of hypoxemia. In this review, the new revised terminology will be used.
Noninvasive positive pressure ventilation (NPPV) is an attractive strategy for children with impending respiratory failure. Since ventilation is delivered noninvasively via mask or other interface, NPPV supports ventilation, can reduce atelectasis, and potentially unloads fatigued respiratory muscles while preserving the child's natural airway and airway clearance mechanisms. In addition, NPPV potentially avoids some of the associated complications of more invasive therapies as well as the need for sedation or muscle relaxation to facilitate these therapies.
NPPV has been used to treat respiratory failure from a variety of etiologies in children, including pediatric ARDS (PARDS). A recent point prevalence study by Santschi et al, in collaboration with the Pediatric Acute Lung Injury and Sepsis Investigators network and the European Society of Pediatric and Neonatal Intensive Care, described the ventilatory strategies for ARDS in 52 PICUs in 12 countries. The authors found significant variability in the use of NPPV among PICUs but described an overall prevalence of 8.5% for the use of NPPV in PARDS.
The use of NPPV in children has increased significantly over the last decade. In one international cohort, investigators found that the use of NPPV increased from 0.5% to 12.2% between 1999 and 2008. Additionally, in a survey of 353 U.S. physicians by Fanning et al, the investigators found that NPPV had been used by 99% of respondents, with 60% using noninvasive support as initial therapy more than 10% of the time. In this same survey, deterrents to use NPPV included lack of experience of staff, lack of appropriate equipment, and proper patient selection. Physicians also reported factors associated with less likelihood of use including severe defects in gas exchange, disease progression, and patient intolerability.
Despite the growing use of this therapy, there are few prospective controlled trials in pediatrics that might guide the clinician in determining indications and strategies for the use of NPPV. Additionally, many studies of NPPV in children include all children with acute respiratory failure and do not differentiate between PARDS and other etiologies. A recent Cochrane review confirmed this assessment, stating that there was a lack of well-designed controlled experiments of NPPV in children with acute hypoxemic respiratory failure.
In this review, we will examine the literature to determine the utility of NPPV in this population and provide recommendations regarding the use of NPPV in children with PARDS. Of note, as the data specific to the use of NPPV in PARDS are limited, the recommendations in this section of the Pediatric Acute Lung Injury Consensus Conference (PALICC) proceedings, while still agreed upon, are less strongly so than in other PALICC topics where scientific literature is more plentiful. Therefore, we suggest that the use of NPPV in PARDS should be considered a crucial research priority in the near future.
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